Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for chronic pancreatitis, evaluation of pain, medication management, or management of complications.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following:
Character, location, and severity of abdominal pain (postprandial pain is suggestive)
Frequency and duration of pain episodes
Factors that worsen or improve pain (e.g., eating, alcohol intake)
Presence of nausea, vomiting, or diarrhea
Weight loss (unintentional weight loss can be a sign of malabsorption)
Past Medical History:
Briefly summarize relevant past medical history, including:
Underlying cause of chronic pancreatitis (e.g., alcohol abuse, idiopathic)
Duration of disease
History of acute pancreatitis attacks
Previous surgeries (e.g., pancreatectomy)
Presence of co-morbidities (e.g., diabetes, malnutrition)
Social History:
Inquire about alcohol intake (crucial for management).
Ask about dietary habits.
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Physical Exam:
Assess for:
Abdominal tenderness
Signs of malnutrition (e.g., muscle wasting)
Laboratory Tests (review recent results):
Lipase and amylase levels (may be elevated but can be normal in chronic pancreatitis)
Electrolytes – assess for dehydration or malnutrition.
Consider additional tests as indicated:
Stool elastase – a non-invasive test to assess pancreatic function (low levels suggest malabsorption).
Imaging studies (CT scan, MRI) – may be used to evaluate the pancreas and identify complications (e.g., pseudocysts).
Assessment (A):
Pain Management:
Evaluate the effectiveness of current pain management strategies.
Nutritional Status:
Assess for signs of malnutrition and risk of deficiencies.
Presence of Complications:
Evaluate for potential complications of chronic pancreatitis (e.g., diabetes, exocrine insufficiency, pseudocysts).
Plan (P):
Pain Management:
Develop a pain management plan based on the severity and characteristics of pain. Options may include:
Lifestyle modifications (avoidance of alcohol and dietary triggers)
Medications (pain relievers, pancreatic enzymes)
Endoscopic procedures (e.g., sphincterotomy) for some patients
Nutritional Management:
Consider dietary counseling and pancreatic enzyme replacement therapy to improve nutrient absorption and manage weight loss.
Management of Complications (if present):
Develop a treatment plan for specific complications identified (e.g., diabetes management, pseudocyst drainage).
Referral (if indicated):
Consider referral to a gastroenterologist or pain specialist for patients with complex pain management or requiring advanced interventions.
Follow-up:
Schedule follow-up visits to monitor pain, nutritional status, response to treatment, and assess for complications.
Define the frequency of follow-up based on disease severity, presence of complications, and treatment plan.
Patient Education:
Educate the patient about chronic pancreatitis, its causes, risk factors, and the importance of treatment adherence.
Discuss the importance of dietary modifications and alcohol abstinence.
Provide information on pain management strategies and potential side effects of medications.
Explain the importance of recognizing signs of malnutrition and complications.
Offer resources for support groups or educational materials on managing chronic pancreatitis.